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General NPI Number Information
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NPI Number | 1285432518
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Entity Type | Organization
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Legal Business Name | SURPRISE ENDO PLLC
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Dates
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Enumeration Date | 03/04/2025
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Last Update Date | 03/04/2025
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Provider Practice Location Address
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Address Line | 15294 W BROOKSIDE LN STE 100
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City | SURPRISE
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State | AZ
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Zip | 85374-2446
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Country | US
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Telephone | 623-376-7400
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Fax |
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Provider Business Mailing Address
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Address Line | 15294 W BROOKSIDE LN STE 100
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City | SURPRISE
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State | AZ
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Zip | 85374-2446
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RYNE JACKSON
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Credential | DMD, MSD
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Telephone | 480-353-6476
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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